Management of NSAIDs-related dyspepsia in the community

Little is known about how non-steroidal anti-inflammatory drugs (NSAIDs)-related dyspepsia is managed in general practice. A survey was conducted to ascertain the preferred methods of investigation and management of NSAIDs-related dyspepsia by GPs in the Leeds district in the summer of 1992. A total of 261/300 (87%) replied to the questionnaire. Most (87%) GPs discontinued NSAIDs, and 12% changed the drug. Only 42 (16%) suggested endoscopy.

Sequential study of bacterial antibody levels and faecal flora in rheumatoid arthritis patients taking sulphasalazine

Faecal and serum samples were collected from 31 patients with active RA during treatment with DMARD sulphasalazine (SASP). These were examined for changes in faecal flora and antibodies to bacterial antigens respectively. Faecal counts of Clostridium perfrigens but not Escherichia coli or total aerobic or anaerobic counts fell significantly after 2 weeks of treatment, this decrease being maintained throughout the treatment period. There was, however, no relationship between changes in the faecal carriage of this micro-organism and response to drug treatment, as assessed using clinical and biochemical indicators of disease activity. Changes in antibody levels to antigen preparations of this organism were also unrelated to response to drug treatment. These results suggest that the anti-rheumatic properties of SASP are independent of its antibacterial effect on bacteria in the bowel and also that neither faecal carriage of, nor antibody responses to this bacterium are involved in disease pathogenesis. Antibody levels to an antigen preparation of Cl. perfringens were found to be significantly lower in those patients who respond well to SASP than those patients who show poor response; this may prove useful as a clinical marker for predicting those patients likely to respond to SASP therapy.

Biomechanics of sports and sports injuries

This overview paper summarizes recent work on the biomechanics of sports activities, prevention and repair of sporting injuries with reports on the papers presented at the Eighteenth Annual Day Conference, held in Leeds on 8 January 1993, by the Bioengineering Group for the Study of Human Joints in association with the Biological Engineering Society.

A clinical and radiological study of back pain in rheumatoid arthritis

Five hundred and three patients with RA were questioned about the symptom of back pain. Chronic back pain, lasting more than 3 months, occurred in 33 per cent of the group. A group of 100 back pain patients were studied in more detail using a structured questionnaire, clinical examination and radiology. Ninety-four of these patients had low back pain. Particular clinical patterns (such as that of the facet syndrome) were sought but no clear characteristics were found. Fifty-two lumbar spine X-rays were available from the RA population and these were compared to 52 age and sex matched X-rays from outpatients with chronic mechanical low back pain. Significant differences between these groups radiologically were a higher frequency of osteoporosis and a higher frequency of disc narrowing without associated osteophytes in the RA population. This study differs from previous reports which found other characteristic radiological features of RA of the lumbar spine (spondylolisthesis, facet erosions, and vertebral fracture), a discrepancy possibly resulting from the use of a control group having low back pain.

Osteoarthritis in weight-bearing wrists?

To test the suggestion [1] that turning the wrist into a weight-bearing joint by using a stick is likely to cause OA in that joint, 50 consecutive patients (excluding those with RA) who had used a stick for more than 1 year were studied clinically and radiographically. The data did not support this hypothesis. The changes in the original paper, as in one of these patients, were likely to be due to avascular necrosis.

Lack of evidence for abnormal fibrinolysis in chronic low back pain

It has been reported that plasma fibrinolytic activity is abnormal in some patients with chronic low back pain. In an attempt to confirm this finding we studied 22 patients with chronic mechanical low back pain and compared them with 18 healthy controls who denied symptoms of back pain. Factors known to interfere with plasma fibrinolysis such as age, weight, seasonal and diurnal variation, exercise, smoking and drugs were controlled as far as possible. Plasma fibrinogen was significantly higher (2.8 versus 2.3 g/l, P < 0.005) in patients than in controls, but there were no significant differences in the median plasma concentrations of euglobulin clot lysis time, fibrin plate lysis area, plasminogen, alpha-2-antiplasmin, tissue plasminogen activator activity, and antigen, tissue plasminogen activator inhibition and plasminogen activator inhibitor-1 antigen level. The results fail to confirm abnormalities of plasma fibrinolytic activity in a group of unselected cases of chronic low back pain.

Endocrine disease

The effects of endocrine disease on bone mass continue to attract attention. Investigations include the effects on the skeleton of thyroid disease, primary hyperparathyroidism, and their treatment. The effect of growth hormone replacement in adults with panhypopituitarism has also been investigated; children with treated growth hormone deficiency appear to reach adulthood with low bone mass. The indications for surgery in asymptomatic primary hyperparathyroidism have recently been reviewed. The associations between autoimmune thyroid disease and connective tissue disease have been investigated. Although patients with Graves' disease are frequently positive for antinuclear antibodies, there appears to be no increased risk of systemic autoimmune disease. The possible pathogenesis of diabetic bone disease via calcium malabsorption, hypercalciuria, reduced bone formation, and collagen abnormalities has been reviewed. A long-term study has clarified the links among diabetic control, limited joint mobility, nephropathy, and retinopathy. The possible mechanisms by which pregnancy may induce remission in rheumatoid arthritis have been discussed.

A double-blind placebo controlled study of desipramine in the treatment of ADD: III. Lack of impact of comorbidity and family history factors on clinical response

A 6-week randomized, double-blind, placebo controlled trial of desipramine (DMI) in daily doses averaging 4 to 5 mg/kg for the treatment of children and adolescents with attention deficit disorder with hyperactivity (ADDH) was further analyzed. Investigators examined whether comorbidity of ADDH with conduct disorder, major depression, an anxiety disorder, or a family history of ADDH predicted response to DMI treatment. There was a highly significant effect of treatment with DMI in outcome assessments, but responses to DMI were indistinguishable in ADDH patients with and without a comorbid disorder or familial ADDH. Cases of "pure" ADDH (lacking comorbidity with depression, anxiety, or conduct disorder and having a positive family history of ADDH) showed a trend toward lesser placebo responses and a corresponding greater DMI-placebo difference. These findings suggest that (1) DMI is effective in simple, noncomorbid cases, (2) DMI is not selective for comorbid cases, but (3) a response to DMI can be obtained even in complex cases of ADDH with associated comorbidity.

Work related upper limb disorder: the relationship between pain, cumulative load, disability, and psychological factors

Repetitive strain injury, or work related upper limb disorder, provides an interesting paradigm for the study of the relative contribution of physical and psychological factors to the resulting pain and disability. Sixty three subjects were studied, comprising the work-force of a subsection of a large local industrial company, in whom pain in the arm related to work was known to be common. Ergonomic data were obtained by estimating the cumulative daily load on the wrist joint for each of four identified tasks. Data on the occurrence of pain, treatment sought, and disability were obtained by a structured self administered questionnaire. Psychological data were obtained by administering the Hospital Anxiety and Depression (HAD) scale, a self reported measure of anxiety and depression, and the Bradford Somatic Inventory (BSI), an inventory of somatic symptoms associated with anxiety and depression. The employment specific period prevalence of work related upper limb disorder was 81%, with 30% of the subjects having pain at the time of the study. Domestic disability was minimal in all but two subjects, though the use of devices such as jar openers at home was common (12 of 51 subjects). Medical advice was seldom sought. Twenty per cent of subjects had received anti-inflammatory drugs, 10% had received physiotherapy, and 47% had wrist splints. Pain was related to the tasks with the highest estimated daily loads, but a history of pain and current pain were associated with higher scores on the HAD and BSI scales, suggesting an interaction between physical and psychological factors.

The effect of non-steroidal anti-inflammatory drugs on faecal flora and bacterial antibody levels in rheumatoid arthritis

The faecal flora and bacterial antibody levels of 22 patients with active rheumatoid arthritis (RA) were compared with those of 26 patients with osteoarthritis (OA) undergoing comparable treatment with non-steroidal anti-inflammatory drugs (NSAIDs), and a further 22 patients with OA who were not receiving NSAIDs. Faecal counts of Clostridium perfringens were significantly higher in the RA patient group and in those OA patients receiving NSAIDs, compared with those OA patients not taking NSAIDs (P = 0.032, P = 0.0004 respectively). Total aerobic and anaerobic counts were, however, identical in all three groups. Levels of serum IgA antibody to the alpha toxin of Cl. perfringens were higher in the RA group and in the OA group taking NSAIDs than in OA patients not taking NSAIDs (P = 0.011, P = 0.055). Serum IgG antibody to alpha toxin was higher in the RA group than in OA patients both on and off NSAIDs (P = 0.019, P = 0.0072) and also a group of normal controls (P = 0.032). These results suggest that the increased faecal counts of Cl. perfringens together with the associated increased antibody levels seen in this and previous studies are more likely to result from NSAID therapy used to treat the disease than from a disease specific change in bowel flora.

Gross motor performance measure for children with cerebral palsy: study design and preliminary findings

This project investigated the validity, reliability and responsiveness of the Gross Motor Performance Measure (GMPM). The GMPM was developed as an observational instrument to measure changes in quality of movement in children with cerebral palsy. Physical therapists from 3 children's treatment centres assessed 107 children with CP, 18 children with head injury and 33 non-disabled children. Assessments were conducted on 2 occasions, 4 to 6 months apart. The measurement protocol included assessment with the GMPM and the Gross Motor Function Measure (GMFM). Validity was tested by comparing changes in GMPM scores to parent and therapist independent ratings of the children's motor performance. Also, a sample (n = 30) of paired assessments was videotaped for 'masked' evaluation by therapists. Inter-rater, intra-rater and test-retest reliability studies (n = 30) were conducted. Responsiveness to change was determined through parent and therapist ratings of the importance of observed changes in quality of movement. Data collection for this study has just been completed. Validation hypotheses have been postulated regarding correlations between changes in GMPM scores; GMFM scores; age of children; diagnosis; severity of condition; parent, therapist and 'masked' evaluator judgement of change. Correlation analysis, t-test and analysis of variance results will be presented. Reliability data for the GMPM and parent/therapist rating scales will be presented using intra-class correlation coefficients. Data supporting responsiveness of the GMPM will be presented using an analysis of variance model for 'stable' and 'responsive' groups.

Gait analysis in ankylosing spondylitis

A study was conducted to compare the gait pattern of 12 patients with ankylosing spondylitis with axial disease only with that of 11 healthy controls using a telemeterised electrogoniometer gait analysis system. The reproducibility of the gait variables was found to be acceptable. Angles for movement at the hip and knee were less in patients with ankylosing spondylitis, but hip/knee angle ratios did not differ between the two groups. The stride length was shorter in the patients with ankylosing spondylitis. These findings are due to the increased rigidity of the spine, which results in decreased shock absorption and consequently a more cautious gait pattern in the absence of clinically and radiologically detectable peripheral joint disease.

From Britain, 1991

Images

The mechanics of soft tissues and soft tissue replacements

A conference, organized by the Bioengineering Group for the Study of Human Joints, was held in Leeds on 10 January 1992.

Growth deficits in children treated with desipramine: a controlled study

Using multiple assessment methods, growth deficits in weight and height were examined in a clinical sample of children and adolescents with attention deficit hyperactivity disorder treated chronically (mean 14 months) with desipramine (DMI) and two comparison samples of children treated chronically with methylphenidate (MPH) and a not-treated group. Although there were statistically significant weight deficits in children treated with both DMI and MPH compared with normal controls, only those treated with MPH sustained height deficits that attained statistical significance. It appears that DMI may be an appropriate alternative for patients with stimulant-associated severe suppression of growth in height.

Survey of satisfaction with care in a rheumatology outpatient clinic

Consumer satisfaction is increasingly recognised by hospital administrators and health care providers as an important aspect of health care. A study was undertaken to investigate the satisfaction with care among patients with rheumatoid arthritis (RA) attending a rheumatology outpatient clinic at Leeds General Infirmary. The Leeds satisfaction questionnaire was developed and rigorously tested for reliability (Cronbachs alpha) and stability (test/retest). The Leeds satisfaction questionnaire was then completed by 70 patients with RA who had attended the Leeds General Infirmary on at least three previous occasions. The results showed that patients were, in general, satisfied with the care they received. The highest satisfaction scores were obtained on the scale for technical quality and competence of health professionals. The least satisfaction was accredited to the difficulty of unscheduled access to the clinic and the lack of continuity with the providers of care. The time spent in the waiting area before consultation was highlighted as the one aspect which caused the greatest dissatisfaction.

Endocrine disorders

The effect of thyroxine replacement therapy on bone mass continues to attract attention. Although the advice of the American Thyroid Association to normalize serum thyroxine and thyroid-stimulating hormone concentrations is recommended, even physiologic doses of thyroxine may have an adverse effect on bone mass. The diagnosis and treatment of osteomyelitis in the diabetic foot is aided by magnetic resonance imaging, and long-term review of cases of diabetic femoral neuropathy emphasizes the good prognosis. Adrenal insufficiency as a complication of antiphospholipid syndrome is reviewed, and a useful physical sign, the acromegalic rosary, rediscovered. The association of sex steroids, oral contraception, and parity with rheumatoid arthritis is discussed. The outcome of pregnancy in women with juvenile rheumatoid arthritis is good, and quiescent disease does not appear to be permanently reactivated. Calcium deficiency, rather than vitamin D deficiency, is a cause of rickets in some Nigerian children.

From aspirin to biologics: therapeutic implications for rheumatoid arthritis

As effective antiinflammatory agents have been added to our armamentarium, 2 major treatment strategies for the treatment of rheumatoid arthritis have developed. The traditional pyramid strategy is based on initial, conservative measures, followed by more aggressive therapy as the disease progresses. The step-down bridge approach is an alternative, more aggressive strategy that favors earlier use of more potent agents. The longterm effects of disease modifying antirheumatic drugs (DMARD) and combination second line therapy on disease progression remain unclear. Advances in the development of more specific DMARD and in human recombinant proteins offer promising future therapies.